ABSTRACT
Objective: This study examined registered nurses’
perspectives of being supportive of nursing students and providing them with learning opportunities when on clinical placements.
Background: In Australia, as part of their three-year Bachelors degree, undergraduate nursing students undertake a minimum of 800 hours of clinical placement. During these clinical placement hours, nursing students are supervised by registered nurses who are required to be supportive of the students and provide them with learning opportunities.
Study design and methods: This study used a grounded theory approach. In this qualitative study there were fifteen registered nurse participants.
Thirteen participants were female participants and two were male. Participants were individually interviewed. Transcripts from these in–depth
interviews were analysed using constant comparative analysis.
Results: The major category, an added extra, emerged from this study. An added extra is about registered nurses’ perception that having a student is an added extra to their daily duties. The major category an added extra is informed by three emergent themes. The first theme was time, the second theme was workload and the third theme was wanting recognition.
Discussion: Registered nurses perceived that their workloads tend not to be taken into consideration when they have nursing students. The literature suggests that nursing students often miss out on learning opportunities when they are on clinical placement because registered nurses do not have additional time to effectively support students’
clinical learning.
Conclusion: Participants in this study believed being supportive of nursing students and providing them with learning opportunities was an added extra to their daily nursing duties. Findings revealed registered nurses want to be recognised for the extra time and effort they dedicate to students’ learning.
Implications for research, policy, and practice:
When allocated nursing students, registered nurses should have their workloads adjusted because being supportive of nursing students and providing them with learning opportunities is time consuming.
Further research is recommended to determine if patient workloads are being decreased when registered nurses are allocated nursing students.
Keywords: Nursing student, workload, preceptorship, qualitative, clinical education
AUTHORS
CARINA ANDERSON RN BN PhD1 LORNA MOXHAM RN PhD MEd2 MARC BROADBENT RN MEd PhD3
1 School of Nursing, Midwifery and Social Sciences, CQUniversity, Noosaville, QLD, Australia
2 School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Keiraville, NSW, Australia 3 School of Nursing, Midwifery and Paramedicine, University
of the Sunshine Coast, Maroochydore DC, QLD, Australia
CORRESPONDING AUTHOR
CARINA ANDERSON School of Nursing, Midwifery and Social Sciences, CQUniversity, PO Box 1128, Noosaville, QLD, Australia 4566. Phone: 07 5440 7032 Email: [email protected]
Recognition for registered nurses supporting students on clinical
placement: a grounded theory study
INTRODUCTION
Across the globe, nursing standards state that when nursing students are on clinical placement registered nurses (RNs) will be supportive of the students and provide them with learning opportunities. The leading body in global health care, the World Health Organization declares that all RNs are required “to supervise and teach” nursing students.1(p26) Countries such as Australia, Canada, Finland, United States of America and United Kingdom also have this requirement embedded within their own nursing standards.2–7 This Australian study examined RNs’ perspectives of being supportive of students and providing them with learning opportunities.
Registered nurses who are licenced to practice in Australia are required by law to practice according to the Nursing and Midwifery Board of Australia’s (NMBA) professional codes and guidelines.8 Within the RN standards for practice it states the RN “actively fosters a culture of safety and learning that includes engaging with health professionals and others, to share knowledge and practice that supports person-centred care”.2(p3) Furthermore the NMBA Code of conduct for nurses states RNs must “commit to teaching, supervising and assessing students…”9(p5) and that it “is the responsibility of all nurses to create opportunities for nursing students”.9(p13) This is important because nursing students rely on RNs for their support during their clinical learning when they are on placements.10
Undergraduate nursing students in Australia are required to complete a minimum of 800 clinical placement hours over the course of their three year Bachelors degree.11 Clinical placement hours are undertaken in either a facilitator or preceptorship model. In the facilitator model a clinical nurse educator oversees the placement of a group of students and these students are then allocated to a RN mentor on a shift by shift basis, whereas, in the preceptor model the student is allocated to an individual RN for (most of) their placement.12 It is not unusual for nursing students to be allocated to a different RN on any given day of their placement. Regardless of which model is used, RNs are bound by their registration requirements to be supportive of nursing students and provide them with learning opportunities.
The impetus for this study came from anecdotal observations of inconsistency in regard to support offered by RNs to nursing students on clinical placement. The study aimed to examine RNs’ perspectives of being supportive of nursing students and providing them with learning opportunities when on clinical placements. The research question being examined was: what are RNs’ perspectives of being supportive of nursing students and providing them with learning opportunities when on clinical placements?
METHODOLOGY
Grounded theory was chosen as the methodology for this project because little research was found around this issue and no theory found on the actual topic itself.13 The study site for this grounded theory study was in Australia. Ethical approval (No: HE12/141) was obtained from the University Health and Medical Human Research Ethics Committee prior to commencement of this research. Participants (n = 15) were RNs who had been licenced to practice for a minimum of five years and had previously worked alongside nursing students.
Participants were from the following nursing designations:
clinical RNs, nursing managers and clinical educators.
Two participants were male and the remaining thirteen were female.
Individual semi structured interviews were recorded using a digital recorder and then transcribed and analysed.
Interviews with participants were approximately forty- five minutes in duration. One researcher was responsible for interviewing participants. As data from each interview was analysed, data was coded, and these codes were sorted into themes. As data was collected, it was compared with existing data using constant comparative analysis technique.
Theoretical data saturation was achieved with fifteen participants; that is, no new information appeared. Four major categories emerged from the data: an added extra, choice, nursing standard and sense of responsibility. This paper reports on one of the major categories that emerged from this study, an added extra.
What is already known about the topic
• Registered nurses struggle to find the time to support nursing students with their clinical learning.
• Management tend not to recognise the time and effort registered nurses dedicate to student learning.
What this paper adds
• Registered nurses perceive supervising nursing students as an added extra on top of their already heavy workload.
• Registered nurses want to be acknowledged for their contribution to student learning.
FINDINGS
The major category an added extra was informed by three emergent themes. The first of these themes was time, the second was workload, and the third was wanting recognition.
AN ADDED EXTRA
This study revealed that RNs believed that being supportive of nursing students on clinical placement and providing them with learning opportunities was an added extra to their [RNs’] allocated work. Despite this, they felt that being supportive of nursing students on clinical placement and providing them with learning opportunities was the right thing to do.
Figure 1 offers a representation of the relationship between the three themes (time, workload and wanting recognition) that inform the major category an added extra. The theme time is about the students taking up an RN’s time. The second theme, workload, is about students adding to an RN’s workload. The third theme, wanting recognition, is about RNs wanting to be recognised for their efforts with students.
These themes all underpin the concept that being supportive of students on clinical placement and providing them with learning opportunities was perceived as an added extra for an RN’s already busy work day.
FIGURE 1: AN ADDED EXTRA
TIME
The emergent theme, time, will be discussed first. Time is about participants asserting that being supportive of nursing students on clinical placement and providing them with learning opportunities takes up their time. Participants explained how they would have to spend extra time in their day to support the students and to provide them with learning opportunities. Part of this was due to students taking extra time to complete a given clinical task and to practice a basic nursing skill.
‘I mean you might be able to do something fairly quickly but the poor old student when they’re learning, they’re learning.
So it will take twice, three times as long … And if your time constraints are really limited that makes it hard. Where I am now, I mean our time constraints are still fairly limited.
We’ve got a certain amount of time we can really allocate to all of our patients that come through and that can change.’
(Participant 5)
‘Teaching takes a lot of time especially if you’re going to go into a little bit of the pathophysiology and a lot of our work now and our own education is leading more towards care of the deteriorating patient. So if you’re teaching that, that takes time.’ (Participant 1)
‘Because having students does take up time. You’re explaining medications or how to give medications or why you’re giving medications, whereas if it was just you on your own you’d just go in and give them. You know why you’re giving them and when they’re due and why they are due then. But when you’ve got the students with you it does take you that little bit extra time to go through and do it.’ (Participant 2)
Participants explained how they wanted management to acknowledge that being supportive of nursing students on clinical placement and providing them with learning opportunities took extra time in their already busy days. In exchange they were asking that their patient workload be decreased so they could have the extra time to support the students and provide them with learning opportunities.
‘Well more time as in … if we’ve got a student cut our workload … if they cut the workload say for example say if I’ve got 8/9 hours work, why can’t I just have 4 and 4. 4 hours like we do when we’re coordinating a shift, 4 hours clinical, 4 hours admin, why can’t the 4 hours admin be for students.’
(Participant 7)
‘I think there needs to be time given for anyone that’s
preceptoring to be able to do that with the student as opposed to the way that we do operate, it’s like okay, [NAME] you’re having the student today and you’re going, you don’t know what their skills are. So then you’ve got to start from the beginning as far as you’re concerned, because you haven’t seen them do anything. Does that make sense?’ (Participant 10)
‘I think that in the workplace when the students are there we need to be able to allocate time to them – for the facilitators.’
(Participant 2)
This participant explained how being supportive of nursing students on clinical placement and providing them with learning opportunities could take up to two hours out of an RN’s day.
‘Unfortunately though I think it comes back to staffing sometimes and availability of staff. They just don’t have the two hours to give you to spend with the student, just to take that extra time out to explain why something’s done this way, or even if it’s to debrief with them something’s that happened on the ward that they’ve had trouble grasping or it’s been traumatic for them or whatever.’ (Participant 2) Indications were that having extra time also benefits a student’s learning:
‘Oh definitely. I mean sometimes yes, when you are doing your teaching and your skills you go a little bit slower so that you might be demonstrating it to the students, when they may be TimeWorkload
Wanting recognition An added
extra
actually taking that skill on board and trying it themselves, you’re going to go a little bit slower but they are teaching moments as well.’ (Participant 10)
Participants voiced that being supportive of nursing students on clinical placement and providing them with learning opportunities takes up an RN’s time. Because of this, participants urged that RNs be given extra time, by decreasing their patient workloads, if they are allocated students.
WORKLOAD
Participants believed being supportive of nursing students on clinical placement and providing them with learning opportunities was something they did on top of their workload. Time and workload are closely aligned.
Participants felt that because of the extra workload that goes with having a student, their patient load should be reduced during this period. Nevertheless, time and workload formed different themes because time is about how being supportive of nursing students and providing them with learning opportunities is time-consuming, whereas workload relates to how having a student adds to an RN’s workload.
The following participant describes the connection between time and workload. They explain how being supportive of nursing students on clinical placement and providing them with learning opportunities takes time, but also that it can intensify their already heavy workloads making the experience stressful:
‘You don’t have that time to stand back which is probably where my anxiety comes from wanting to do it for them and wanting them to make that connection a lot faster … You know instead of being able to stand back and let – just watch. I want to do it for them because I still know that I’ve still got X, Y and Z to do and this is only T.’ (Participant 1)
These participants explained how having a student added to their workload:
‘When I worked on the wards sometimes it could be really hard because … you’d just seem to be overwhelmed sometimes with the work … the work demands plus you’re trying to teach at the same time.’ (Participant 2).
‘So, if you’re doing that and then you’re going on to the next procedure that you might be doing or the next thing, or debriefing, you might go and talk to a family that has a dying – well the family of a dying person, so you’re dealing with that and then you come out and the person’s – the student can maybe see – some of them have never seen a dying patient. So then you’re talking that through. So by the end of 8-hours you haven’t just done your 8-hours work, you’ve also done 8-hours of coaching. So to – you have to be fair to the nursing staff. They are on shift work, they are carrying a heavy load and they’re also having students.’ (Participant 8)
Although it was indicated that having students added to the workload, participants also described how they were still
“happy to have students”.
‘Yes it does. We always had student nurses when I trained so I couldn’t draw from that experience, it was always first, second and third year nurses on the ward and if you were a second year nurse you looked after the first year nurses. If you were a third year nurse you looked after the rest. So, yes it does add to your workload but I wouldn’t say in a negative way.’
(Participant 12).
This participant affirmed that workload should be taken into consideration when RNs are allocated students.
‘Absolutely happy to have students. Really need to look at the workload if you’re given a student.’ (Participant 1)
Because of the perceived extra workload associated with having students, participants also said they wanted recognition for being supportive of students and providing them with learning opportunities.
WANTING RECOGNITION
The theme wanting recognition is about participants saying they wanted to be recognised for the extra effort and time they took to be supportive of students and provide them with learning opportunities. This participant indicated that RNs did not want gifts or money; they just wanted to be acknowledged that they put in time and effort into the students’ learning:
‘I think especially if they’re allocated a specific student for the whole duration and that student works the shifts that they work, I think there should be some – it doesn’t have to be big recognition, but just a certificate to say that they have preceptored the student, or mind you the students are often recognising the staff they work with anyway…But, yes I think they do, they want recognition that they are doing this and I don’t think it’s so much monetary or like a gift or anything, just to be acknowledged that that’s what they’ve done…and you hear it when you’re in senior meetings and things – the discontent or the concerns that staff raise so – and in senior meetings you tend to hear the same recurring theme as well, and it is things like you know we just want to be given some recognition that we are doing this with our students and especially when there’s some that don’t have students at all.’
(Participant 9)
This participant also suggested that RNs should be rewarded with a certificate when they have done the added extra work with students.
‘I think at the end of the day they should be rewarded with a really nice sort of certificate saying look, outstanding contribution to undergraduates’ placement’ (Participant 7)
This participant described how certificates of acknowledgment can make an RN feel appreciated:
‘Where they have the person’s name on a certificate on the wall, so you’re walking past you might see somebody’s name ten times … Yes, it sort of feels good at the end of the day.’
(Participant 7)
Finally this participant was adamant that RNs need to be rewarded when they have been supportive of nursing students on clinical placement and provided them with learning opportunities.
‘And even some sort – even if it was a pen or a notepad or something – who’s going to thank them for it at the end of the day, but at the end of the day the registered nurse has to be rewarded.’ (Participant 7)
Findings revealed that participants believed being supportive of nursing students on clinical placement and providing them with learning opportunities was an added extra to their normal duties. Participants described how being supportive of nursing students and providing them with learning opportunities was both time consuming and increased their workload. As such participants indicated that RNs would like to be recognised for their contribution to student learning.
DISCUSSION
The concept that having a student is an added extra was found to be a repetitive theme in this study. Other studies also support the notion that being supportive of students and providing them with learning opportunities is perceived as an added extra for RNs.14,15
Congruent with findings from this study, the literature also supports the notion that being supportive of students when they are on clinical placements and providing them with learning opportunities takes up RNs’ time.16,17 Registered nurses often feel they are too time poor to spend the extra time that it takes to provide students with quality learning opportunities.18 This has been highlighted as a major concern for RNs who are keen to assist the students in their clinical learning.19 McInnes, Peters, Hardy and Halcomb suggest that RNs who are given students should be allocated extra time so they can be supportive of the students and provide them with quality learning opportunities.20
According to Madhavanpraphakaran, Shukri, and
Balachandran RNs struggle balancing their patient workload and helping students with their clinical learning. Workload pressures can adversely effect the quality of students’ clinical learning during their placements.21,22 Yonge, Krahn, Trojan, Reid and Haase describe how management tends to disregard the additional workload that accompanies having a student.
Furthermore they assert that because of the extra workload that goes with having a student, patient care can be affected.
Finally they suggest that patient loads need to be decreased if
Regardless of the evidence in the literature that recommends RNs’ workloads be reduced if they have students, in the real world RNs are not a given a lesser workload when they are allocated students.15 Concerns about the additional workload associated with having student makes some RNs not want students at all.23 Students are sometimes left with minimal clinical supervision because the RNs’ workload does not allow time for the student.24 This can result in students being deprived of important learning opportunities which can ultimately affect their ability to learn how to practice safely.
Management needs to be cognisant of how [lack of] time and workload can affect students’ learning.
Between the years 2011 to 2013 clinical placements cost the Australian government approximately $425 million.25 Clearly, in Australia, large amounts of money are vested into clinical placements for nursing students. With this in mind it would not necessarily be cost-effective for government or healthcare agencies to decrease RNs’ workloads when they have students as this would mean that even more money would be spent on clinical placements. According to findings from this study however management should give RNs extra time by decreasing their workload when they are allocated students.
Increasing staffing levels to accommodate student learning may be a financial issue at the healthcare facility and may appear to be beyond nursing management’s jurisdiction, however creating a healthy and manageable work
environment is important in order to achieve best healthcare outcomes for patients.
Registered nurses also want recognition for the time and effort they spend being supportive of nursing students and providing them with learning opportunities.26 Evans, Costello, Greenberg and Nicholas found that RNs can become disheartened and not want students because the extra work that goes with having a student is not necessarily acknowledged by management.16 The literature supports the finding that RNs want some sort of acknowledgement for the additional effort and time they dedicate to being supportive of students and providing them with learning opportunities.27 Both healthcare management and tertiary institutions should acknowledge RNs’ efforts with students.
LIMITATIONS
There are some limitations to this study. The researchers acknowledge that prior to the commencement of the study they had a preconceived idea that students were experiencing a lack of support from RNs during clinical placements. To avoid researcher bias, the researchers were careful not to allow their own preconceptions and personal opinions to influence the outcomes of the research by remaining objective during the entire research process.28 Being a qualitative study, the sample size was not large (n = 15) and participants were recruited from only one Australian state:
Queensland. That being said, the aim of grounded theory research is not to gain statistical data, rather it is to gain a deep understanding of a given social phenomena.
CONCLUSION
Results from this study revealed that participants perceived that having nursing students and providing them with learning opportunities is time consuming and adds to their workload. As such RNs in this study expressed a desire for recognition and acknowledgement of the extra work that is required in supporting a student; particularly from management. The participants believed RNs’ workloads should be reduced if they are allocated students so they have more time to be supportive of the students and to enable them to provide quality learning opportunities. This study is important because management needs to be mindful of the extra time involved in having a student and to adjust the RNs’ workload accordingly when they are allocated students.
Furthermore management and the tertiary sector need to acknowledge RNs’ efforts for working with students. In summary RNs in this study believed that being supportive of nursing students and having to provide them with learning opportunities was an added extra to their daily duties.
RECOMMENDATIONS
• Registered nurses need to be acknowledged for the time and effort they dedicate to student learning.
• Nursing management should decrease RNs’ patient workloads when they have nursing students.
• Increase the overall ratio of RNs in the workplace to enable RNs to have the extra time to be supportive of nursing students and to provide them with learning opportunities.
This, in turn, will increase patient safety thereby resulting in better patient outcomes.
Acknowledgements: The authors of this paper would like to acknowledge CQUniversity’s School of Nursing, Midwifery and Social Sciences, University of Wollongong’s Faculty of Science, Medicine and Health and University of the Sunshine Coast’s School of Nursing, Midwifery and Paramedicine.
Funding support: No funding support was received for this study.
Conflict of Interest: The authors have no conflict of interest to disclose.
REFERENCES
1. World Health Organization. Nursing & midwifery human resources for health: global standards for the initial education of professional nurses and midwives [Internet]. Geneva, Switzerland: WHO Press; 2009 [cited 2019 Jun 11]:
https://www.who.int
2. Nursing and Midwifery Board of Australia. Registered nurse standards for practice [Internet]. Melbourne, Vic: Nursing and Midwifery Board of Australia; 2016 [cited 2019 Jun 11]:
https://www.nursingmidwiferyboard.gov.au
3. Canadian Nurses Association. Framework for registered nurse prescribing in Canada [Internet]. Ottawa, Ontario: Canadian Nurses Assocation; 2015 [cited 2019 Dec 17]:
https://www.cna-aiic.ca
4. Flinkman M, Leino-Kilpi H, Numminen O, Jeon Y, Kuokkanen L, Meretoja R. Nurse Competence Scale: a systematic and psychometric review. J Adv Nurs. 2017; 73(5):1035–50.
doi.org/10.1111/jan.13183
5. Anderson CC, Moxham LJ, Broadbent M. Is provision of professional development by RNs to nursing students a choice?
Aust J Adv Nurs. 2018;35(4):34–41.
6. American Nurses Association. Nursing: Scope and standards of practice. 3rd ed. Silver Spring, Maryland: American Nurses Association; 2015.
7. Nursing and Midwifery Council. The code: Professional standards of practice and behaviour for nurses and midwives [Internet]. London: Nursing and Midwifery Council; 2018 [cited 2020 Dec 13]: https://www.nmc.org.uk
8. State of Queensland. Health practitioner national regulation law Act 2018. Queensland: Parliamentary Counsel; 2018.
9. Nursing and Midwifery Board of Australia. Code of conduct for Nurses [Internet]. Melbourne, Vic: Nursing and Midwifery Board of Australia; 2018 [cited 2019 Jun 11]:
https://www.nursingmidwiferyboard.gov.au
10. Daly J, Speedy S, Jackson DB. Contexts of Nursing 4th ed.
London: BMJ Publishing Group Ltd; 2014.
11. Australian Nursing and Midwifery Accreditation Council.
Registered nurse accreditation standards 2012. Canberra:
Australian Nursing and Midwifery Accreditation Council; 2012.
12. Walker S, Dwyer T, Moxham LJ, Broadbent M, Sander T.
Facilitator versus preceptor: Which offers the best support to undergraduate nursing students? Nurse Educ Today.
2013;33(5):530–5. doi.org/10.1016/j.nedt.2011.12.005 13. Strauss A, Corbin, JM. Basics of qualitative research :
techniques and procedures for developing grounded theory.
2nd ed. Thousand Oaks: Sage Publications; 1998.
14. Yonge O, Krahn H, Trojan L, Reid D, Haase M. Being a Preceptor Is Stressful! J Nurses Prof Dev. 2002;18(1):22–7. doi.
org/10.1097/00124645-200201000-00005
15. Henderson A, Eaton E. Assisting nurses to facilitate student and new graduate learning in practice settings: What ‘support’ do nurses at the bedside need? Nurse Educ Pract. 2013;13(3):197–
201.doi.org/10.1016/j.nepr.2012.09.005
16. Evans L, Costello, M., Greenberg, H., Nicholas, P. The attitudes and experiences of registered nurses who teach and mentor nursing students in the acute care setting. J Nurs Educ Pract.
2013;3(2).
17. Andrews CE, Ford K. Clinical facilitator learning and
development needs: Exploring the why, what and how. Nurse Educ Pract. 2013;13(5):413–7. doi.org/10.1016/j.nepr.2013.01.002
18. Jokelainen M, Jamookeeah D, Tossavainen K, Turunen H. Finnish and British mentors’ conceptions of facilitating nursing students’
placement learning and professional development. Nurse Educ Pract. 2013;13(1):61–7. doi.org/10.1016/j.nepr.2012.07.008 19. Broadbent M, Moxham L, Sander T, Walker S, Dwyer T.
Supporting bachelor of nursing students within the clinical environment: Perspectives of preceptors. Nurse Educ Pract.
2014;14(4):403–9. doi.org/10.1016/j.nepr.2013.12.003 20. McInnes S, Peters K, Hardy J, Halcomb E. Primary care clinical
placements: The views of Australian registered nurse mentors and pre-registration nursing students (part 2). Nurse Educ Pract. 2015;15(6):443–9. doi.org/10.1016/j.nepr.2015.04.004 21. Madhavanpraphakaran GK, Shukri RK, Balachandran S.
Preceptors’ perceptions of clinical nursing education. J Contin Educ Nurs. 2014;45(1):28–34. doi.org/10.3928/00220124- 20131223-04
22. Nielsen AE, Noone J, Voss H, Mathews LR. Preparing nursing students for the future: An innovative approach to clinical education. Nurse Educ Pract. 2013;13(4):301–9.
doi.org/10.1016/j.nepr.2013.03.015
23. Hanson SE, Macleod ML, Schiller CJ. ‘It’s complicated’: Staff nurse perceptions of their influence on nursing students’
learning. A qualitative descriptive study. Nurse Educ Today.
2018;63:76–80. doi.org/10.1016/j.nedt.2018.01.017 24. Clements AJ, Kinman G, Leggetter S, Teoh K, Guppy A.
Exploring commitment, professional identity, and support for student nurses. Nurse Educ Pract. 2016;16(1):20–6.
doi.org/10.1016/j.nepr.2015.06.001
25. Australia HW. Australia’s future health workforce - Nurses.
Canberra: Department of Health; 2014.
26. Kumar S, Lensink I, Turnbull C. Tips for using students during times of change in health care: lessons from the literature and from practice. Adv Med Educ Pract. 2017;8:535–40.
doi.org/10.2147%2FAMEP.S141414
27. Aglen B, Louise Soro V, Orvik A, Haugan G. Preceptorship during health personnel students’ clinical studies in nursing homes- An institutional perspective on an intervention. Nurs Open.
2019;6(1):144–54. doi.org/10.1002%2Fnop2.197
28. Charmaz K. Constructing grounded theory a practical guide though qualitative analysis. London: SAGE Publications Ltd.;
2006.